Is there any information we should have regarding the welfare of this attendee; handicaps, restrictions, diets, etc?

Is there any activity you do not wish him/her to participate in?

Yes No

If yes, please explain:

Check if child has ever had the following:

Measles Polio Mumps Chicken Pox

List anything your child is allergic to:

List information concerning medications to be given away from home:

Is your child covered by insurance?

Yes No

If yes, what is the Insurance Company:

Policy #:

Medical Consent: I do hereby state that I have legal custody of this child, a minor, who resides with me. While this minor is at First Assembly Memphis and Hopewell Camp and Conference Center, I hereby authorize any director, staff member, nurse, dean, lifeguard, or other responsible person of said camp to consent to any x-ray, examination, anesthetic, medical or surgical treatment, and hospital care, to be rendered to this minor under the general or special supervision and on the advice of any physician or surgeon licensed to practice in the United States, when such medical or surgical treatment is necessary. I further understand that my personal health insurance will be the policy information is provided by myself, I will be personally responsible for any medical charges incurred. I also give permission for my child to receive over-the-counter medication from the camp first aid station if necessary. (Parent/guardian initials)

Discipline/Property Consent: I understand that First Assembly Memphis and Hopewell Camp and Conference Center make rules and guidelines that my child will abide by while attending camp. I understand that if my child misbehaves and does not respond in a positive manner, I may be called to pick him/her up. Warnings will be given, but if inappropriate behavior continues, I will come and get him/her and no refund will be issued. In addition, I will pay for any damage that is done to the camp and/or to personal property belonging to another individual. I give permission to the retreat director and/or assistant director to inspect the contents of any or all of my child's personal belongings, and to withhold and/or dispose of any improper or illegal contents. (Parent/guardian initials)

Activity Consent: I give my permission for my child to participate in all retreat-related activities. I understand by signing this release form, I am assuming such risks that are both known and unknown to me at this time. (Parent/guardian initials)

Promotional Consent: I consent to the use of any videotape, photographs, audiotapes, or any other visual or audio reproduction in which my child may appear by First Assembly Memphis. I release First Assembly Memphis from any liability connected with the use of picture or voice recording as part of any promotion, recruitment, or fund-raising program. (Parent/guardian initials)

Signature of Parent/Guardian

Clear

You will be sent to our payment page after submitting this form. Cost of trip is $110 per student. You may skip payment page if you wish to pay cash or by check. Make check payable to First Assembly Memphis. If you wish to pay online, please put Youth Fall Retreat in Memo portion. Payments are due no later than October 28. Thank you for registering for a wonderful weekend!